Do the Right Thing: A Notable Case STEVEN E. ZIMMET, MD PRESIDENT, AMERICAN BOARD OF VENOUS & LYMPHATIC MEDICINE
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n this, my last public commentary about our field, let me tell you about a case, a legal case. Three and a half years ago, I was contacted by the Department of Justice. A physician was performing a large amount of vein ablations on Medicare patients, and they were concerned about Medicare fraud. I agreed to review a few charts. After finding serious cause for concern, I agreed to review 42 patient files with about 8,000 pages of records and images. Sadly, it was obvious to me that these elderly patients, many of whom had significant medical problems and contraindications, didn’t need these ablations. The physician had billed Medicare about 12 million dollars over a 3-year period. One wonders how much he billed patients with other insurance coverage. Not only did he perform unnecessary procedures, but he also up-coded using 37241, often charged for doing two procedures on the same vein (GSV) at the same time, and was storing used endovenous ablation devices for re-use. After an exhaustive review of the records, it was clear the standard of care was horrendous with examples throughout the records including:
• Completely inadequate venous H&P’s • Missing duplex ultrasound physician interpretation reports, or reports by the radiologist dictated as long as five months after treatments had been done • Missing duplex ultrasound images or images that did not show reflux • Consent forms that were signed after the first treatment and/or were for a procedure different than what was actually done • Operative notes that did not match what vein was said to be treated • Treatment done in the face of clear contraindications The number of ablations was astounding with the physician performing an AVERAGE of more than four ablations per patient and recommending almost six ablations per patient. One 80-year-old patient had 10 veins ablated (with complications), and yet a follow-up ultrasound after all that was said on the technologist’s worksheet to demonstrate reflux in another 7 veins! Review of the actual images revealed otherwise. 26
It was helpful at trial to be able to point to the recent article in Journal of Vascular Surgery: Venous and Lymphatic Disorders about utilization of venous ablation in the Medicare population, across 10,000 providers and more than 340,000 patients from 2012-2015 revealed the average patient needing ablation required 1.8 ablations1, along with registry and other data. Given all this, one would expect it to be hard for the defense to find an expert to testify on his behalf. For a long time, they did not have an expert. I was shocked and angry that a few months before going to trial a board-certified vascular surgeon agreed to serve as their expert. He said he was also an RVT, but a check of his certification status online and by phone call reveals his certification was revoked in 2014, presumably because he did not meet their MOC requirements. He also advertises as an expert witness with his ad listing saying he has given more than 10 depositions or testimonies over the last 4 years. By the way, I’m pretty sure that none of us know this person. He doesn’t attend any of our meetings (AVLS, AVF), though he was briefly a member of the ACP. His first two-and-ahalf-page report was so bad, he was not accepted as an expert
